Section 17
Menopause: Culture, Expectations, and Clinical Conclusions

Cross-cultural comment
North America is a diverse part of the world, with many cultures reflective of other parts of the world. Children do not leave home in every culture. In some societies, it is only the sons, or more frequently the daughters, who leave home to become part of a husband’s family. Although many Americans attend university far from home, and Americans move, on average, every few years, there are families whose adult children take jobs, marry, and raise families close to their parents. Many cultures accord aging women considerable respect. There is also considerable gratification and respect inherent in the accomplishments of a woman’s adult and independent children. Many, perhaps most, mothers, throughout history, have not had the luxury of spending all their time attending to their children. The middle class is a relatively recent social development. Wealthy women have generally hired other women to care for their children. Poor women have had to contribute to the family economy by participating in the work of a family business or farm or earning money outside the family. The Western concept of the empty nest is predicated upon the assumption that women do nothing else than, and find satisfaction only in, caring for their children. It does not acknowledge that menopause may bring women welcome relief from the responsibilities of caring for young children.

Motherhood is not intrinsic to being female. Women without children, however, incur considerable social pressure in most cultures. The choice to have children is seldom challenged, while women who do not have children have to defend this status repeatedly, even when infertility makes having children impossible. In the past, overt homosexuality was incompatible with parenthood. Now, lesbian women may or may not have children. Many engage in heterosexual as well as homosexual activities. Others discover or acknowledge their homosexuality only after marrying and having children. Still others adopt children, or undergo artificial insemination, whether in a medical setting or independently. The experiences of lesbian and bisexual women vary enormously from culture to culture, and from subculture to subculture within the United States. At menopause, the social pressure towards heterosexuality may diminish as the possibility of childbearing diminishes and as women become more comfortable with their sexual orientation.

The generation gap
Changes in social expectations can cause dissonance between the expectations of a mother and those of her children and between subcultures and the larger society. While privileged and educated women fight for the rights of women to participate in the world of paid employment, there are women who regard leaving the paid workforce and being supported by a husband as an accomplishment. The changes in the roles of women in society can produce family tensions. Some menopausal women have looked forward to putting their energy and talents into new careers or advancement in their ongoing careers when their children become independent. Their children, on the other hand, may expect them to be available to prepare holiday meals and care for their grandchildren. On the other hand, some women have looked forward to becoming traditional grandmothers, preparing baked treats for the family and entertaining their grandchildren. Their children may feel they are wasting their talents, assuming a lower status in society than they would like.

Disappointments
Menopause occurs at approximately the same time when people reflect on their lives and compare their accomplishments and situation with their expectations. Since half of all marriages in the United States end in divorce, it is likely that a large percentage of menopausal women do not have the relationships they hoped to have when they were younger. Their children may not have the jobs, mates, homes, or attitudes they envisioned when the children were born. Educational aspirations interrupted by lack of funds, marriage, childbearing, and childrearing may now never be realized. Parenthood may no longer be a possibility. Menopause can be a time for resignation.

Decisions
Menopausal women have been the subject of a major medical controversy: whether the benefits of exogenous hormones outweigh the risks, and what the benefits and risks actually are. When today’s menopausal women were growing up, physicians made medical decisions and patients accepted those decisions. The medical consumer movement began and flourished during their youth. Now they have to make decisions about hormone treatment and other aspects of medical care. It is increasingly clear that the medical establishment does not have the final answers to their questions. Some physicians will still expect patients to follow orders without question. Others will offer medical statistics and refuse to give advice. Women’s decisions, and relationships with medical professionals, will also be influenced by their past experiences with reproductive health care, including their experiences of childbirth. Their current decisions can be informed by their decades of life experience.

Clinical conclusions
Traditional psychoanalysts believed that patients’ responsiveness to psychodynamic treatment decreased as age advanced beyond maturity. As the above paragraph illustrates, the opposite can be true. Menopausal women bring many assets to psychotherapy, although, during acute or chronic mental illnesses, they often do not realize it. In addition to all the other psychotherapeutic techniques that may be employed, it is important for therapists to underscore patients’ accomplishments, experiences, and hard-won maturity.

Specific issues for psychotherapy at menopause include relationships with partners and children, and permission to pursue personal interests. Some women need help disengaging from the lives of their adult children. Others have difficulty accepting help from their children. It is often helpful to point out that helping their parents is an important gratification for adult children. Similarly, the freedom to explore new activities can be cast, for women who see such activities as self-indulgent, as the fulfillment of a responsibility to utilize one’s talents. Menopause is a psychologically fertile time for women, as they master the tensions between expectations, realities, and possibilities.

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Reflection Exercise #10The preceding section contained information
about culture, expectations, and clinical conclusions in menopause. Write three case study examples
regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 17 According to Stotland, the Western concept of the empty nest is predicated upon the assumption that women do nothing else than, and find satisfaction only in, caring for their children. What does it not acknowledge?
Record the letter of the correct answer the CEU Answer
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